The organic
nitrates have remarkably diverse actions that are or should be beneficial in patients with
ischemic heart disease. These drugs are effective in all the important ischemic syndromes. Preliminary data in patients with acute
infarction suggest that the drugs may be truly cardioprotective, resulting in improved mortality. This review has not discussed the role of
nitrates in
congestive heart failure or
LV dysfunction, a subject of great importance. The
nitrates are useful adjunctive agents in these syndromes, and the two VeHfT trials support the concept that long-term
nitrate administration, in conjunction with
hydralazine, may favorably alter the natural history of
heart failure. This cardioprotective effect is similar to that suggested for the post-MI patient. The data are not strong enough for definitive conclusions at this time. The clinical benefits of
nitrates in decreasing subjective (angina) and objective indices of
ischemia in stable and
unstable angina, as well as limited data in asymptomatic
myocardial ischemia, are unequivocal and are as favorable as those for beta blockers or
calcium antagonists. Tolerance is an important problem that unfavorably influences the potential benefits of
nitrate therapy. I believe that this problem can be avoided with well-designed dosing regimens. Current research into endothelial biology in health and disease has further supported a physiologic role for the organic
nitrates in patients with
ischemic heart disease. The
nitrate-platelet story, while controversial, is promising and offers another positive rationale for
nitrate administration. The concept of
nitrates replenishing disordered EDRF release or action is an exciting one. Physicians should feel fortunate to have such a remarkable group of drugs available for their patients.